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2019 STUDY OF QUALITY-STANDARD 4.7

by Cecylia K. Mizera, M.D. | Dec 23, 2019

PROBLEM:
Localization of breast lesions in the radiology department prior to surgery often leads to long wait times between localization and surgery for the patient or delays in the start of surgery due to prolonged wait times in the radiology department. We can identify surgery start times/time into surgery time. But we cannot directly attribute delays to the wire loc. When patients need to wait more than one hour from the time their localization is performed to the time of surgery, this increases the patient's anxiety and decreases satisfaction. 

RATIONALE FOR STUDY:
When OR times are delayed due to a patient being delayed in the radiology department, this results in departmental inefficiencies, clinical inefficiency of providers and lost revenue. 

Decoupling the radiology localization process from the surgical time can improve patient satisfaction, decrease patient anxiety, and improve departmental efficiency and capture revenue. 

STUDY METHODOLOGY:
2019 breast cancer and excisional biopsy surgical cases that had needle localization (either US or mammography guided) were reviewed for a total of 50 cases

32 cases were biopsy proven cancers (25 IDC, 5 DCIS, 2 both IDC and DCIS). 
18 cases were excisional biopsy cases with high risk findings. 11 cases had benign final pathology. 7 cases had final pathology which showed cancer. 
This represents 38% of excisional biopsies coming back with a cancer diagnosis. 

Evaluated 50 cases for scheduled surgery time and time in the surgical suite.
40 cases or 80% started late. Average of 33.04 minutes. 
Evaluate only 40 late cases vs. all 50 cases- average of 45 minutes.
10 cases or 20% started early. Average of 18.1 minutes

A telephone survey was conducted on each of these cases asking 3 main questions.

    1. When asked if they waited a long time between wire localization and surgery start time patients replied: 

     

      Yes- 9 patients or 18%
      No- 40 patients or 80%
      Neutral- 1 patient or 2%
    2. When asked if waiting time between wire localization and surgical start time increased their anxiety about the surgery patients replied:

      Yes- 17 patient or 34%
      No- 32 patients or 64%
      Neutral- 1 patient or 2%
    3. When asked if they would prefer transmitter placed in breast between time of surgical consultation and day of surgery patients replied:

      Yes- 25 patients or 50% 
      No- 25 patients or 48%
      Neutral 1 patient or 2%
Patients who did not want the change were most concerned about taking another day of work.

Patients who wanted the change cited the following reasons: felt that less waiting time day of surgery was desired, felt the wire day of surgery was uncomfortable, and less time at the hospital day of surgery was desirable.

Reasons for anxiety included: worry about the surgery, finding the surgery to be an anxiety producing situation, the wait itself made them more anxious, the wire was uncomfortable.

2 patients stated they were always anxious and one cited a delay in transport pick up resulted in increased anxiety.

Patients who stated that they were not anxious stated it was because of proper preparation by surgeon, WHC staff, and the PACU staff, good explanations, reassurance given by staff, and support by the nurses. A few patients had had surgery before and knew what to expect. Two patients had taken anti-anxiety medicine. Several cited family support and/or prayer.

The interesting finding here is that twice the number of patient were not anxious and they attributed that to staff support. This is showing that our staff were able to have a positive effect on the patient's anxiety level in spite of wait times. 

RESULTS: 
The vast majority of breast excisions with wire localizations started an average of 30 minutes later than scheduled times.  This translates to surgeon and operating room inefficiency. 

Although the majority of patients did not report a perception of prolonged wait times, this may have been mitigated due to staff explanations of what is “normal and expected”. Despite this, about a third of patients still reported anxiety due to wait time between procedures. At least half of the patients were open to wire-free localization procedure as an alternative option. 

CONCLUSION:
Evaluation of a wire-free method of localization which would de-couple the process of localization from the breast surgery is validated by the potential benefits and mitigation of the identified issues of OR efficiency and patient anxiety. 

PLAN OF ACTION:
Wire free localization de-couples the procedure of the lesion localization in the radiology department form the breast surgery by allowing the localization procedure to be done days, weeks, or months in advance of the planned surgery. Three options of wire-free breast localization were evaluated.

    1. Radioactive Seed
    Because of the following disadvantages, this option was ruled out: clinicians need to be certified for handling the radioactive seed. Disposal of the seed can be disruptive to the specimen and requires specialized protocols and procedures which can be expensive. Patients are concerned about safety. 

    2. MagSeed
    Because of the following disadvantages this option was eliminated:  leaves a large artifact on MRI so it is not the best option for patients who undergo neoadjuvant chemotherapy or who require MRI after biopsy has been completed during which the seed was placed. 

    3. Scout Radar Localization
    This option was chosen because of the following advantages:
    Reflector can be placed in the breast anytime between biopsy and surgery. It can be left in place indefinitely if there are any delays or changes in the treatment plan. The reflector is completely MRI compatible and does not leave any artifact. 

    Distance from the detector to the reflector is measured by the system. This assists in the application of oncoplastic techniques and can help in the assessment of margins intraoperatively. The deflector has also been approved for placement in the axillary lymph nodes to assist in resection of biopsy proven positive lymph nodes after neoadjuvant chemotherapy.
We will change to the Scout transmitters and evaluate 50 cases.
Look at the re-excision rate in these cases. Compare to 2019 data.
Compare scheduled surgery time to time into surgical suite. Compare to 2019 data.
Use telephone survey to evaluate the patient's experience and perceptions.